HEENT Disorders Flashcards
Clinical manifestations of necrotizing (malignant) otitis externa
- Exquisite otalgia and otorrhea
- Not responsive to topical measures
- Pain tends to be worse at night
- Radiates to temporomandibular joint (pain with chewing)
- May have facial or vagal nerve palsy
Diagnosis of necrotizing otitis externa
CT of temporal bone
Tx for necrotizing (malignant) otitis externa
Antipseudomonal double-coverage
E.g. Piperaciilin and Gentamycin
Cipro reasonable alternative if patients cannot take one of above
Surgerical debridement may be necessary, involve ENT
Causes of corneal abrasion
- Direct trauma (usually) But also... - Contact lens irritation - UV light exposure - Wind exposure
When does tracheoinnominate artery fistula form s/p tracheostomy?
More than 48 hours after procedure and within 3 weeks of placement
Management for tracheoinnominate artery fistula
- Attempt tamponade with overinflation of cuff
- Secure airway with endotracheal intubation
- Remove tracheostomy tube
- Digital compression of innominate artery
How long does it take for a tracheostomy tract to mature?
5-7 days
Tracheostomy Complications
- Accidental decannulation, obstruction, infection, bleeding
- Tracheo-innominate artery fistula - usually within first 3 weeks with peak incidence between first and second week
Cause of cavernous sinus thrombosis
Late complication of infection of paranasal sinuses (rarely caused by bacteremia or infections of maxillary teeth)
Clinical manifestations of cavernous sinus thrombosis
- Headache
- High fever
- Periorbital edema and chemosis (conjunctival edema)
- Cranial nerve palsies (CN VI most common - lateral gaze palsy)
- Decreased visual acuity
PERIORBITAL EDEMA AND VISION CHANGES CAN RAPIDLY BECOME BILATERAL DUE TO COMMUNICATING VEINS BRIDGING CAVERNOUS SINUSES
Dx of cavernous sinus thrombosis
CT scan
*Definitive dx -> MRI with venography
Tx for cavernous sinus thrombosis
- IV abx including vancomycin, ceftriaxone, and metronidazole
- Controversy regarding heparin
- ENT consultation
Structures passing through cavernous sinus
- Internal carotid
- Oculomotor nerve (III)
- Trochlear nerve (IV)
- Abducens nerve (VI)
- Ophthalmic div (V1)
- Maxillary div (V2)
Etiologies of chorioretinitis (posterior uveitis)
- Infectious (toxoplasmosis, CMV, HSV)
- Systemic immune-mediated (sarcoid, multiple sclerosis, Lupus, Kawasaki)
- Drug reactions
Uvea includes:
- Iris
- Ciliary body
- Choroid
Q#105523
Chorioretinitis presentation
Typically unilateral with decreased visual acuity and floaters
Patients with HIV/AIDS can have atypical features such as necrotic lesions and bilateral findings
Difference between vestibular neuritis and labyrinthitis
Vestibular neuritis = rapid onset of severe vertigo, nausea, vomiting
Labyrinthitis = Vestibular Neuritis + Unilateral sensorineural hearing loss
Tx for labyrinthitis
- Corticosteroids
- Symptomatic meds like Benzos and antihistamines
Weber Test
Normal: no lateralization
Sensorineural loss: sound localizes to unaffected ear
Conductive loss: sound localizes to affected ear
Clinical features of anterior scleritis
- Severe, constant, boring pain that worsens at night or early morning
- Radiates to face and periorbital region
- Ocular movements exacerbate pain
- Headache, watering of eye, redness
- Often associated with systemic diseases like rheumatoid arthritis
- Visual acuity may be normal or decreased
Differentiating factor between scleritis and episcleritis
Scleritis - no improvement in erythema with phenylephrine
Episcleritis - typically self-limited or quickly responsive to topical therapies
Tx of scleritis
- NSAIDs
- Glucocorticoids
- Immunosuppressives
Most common site involved in oral cancer?
Tongue
Sx of oral cancer
- Nonhealing ulcerations, initially painless, but may have exophytic lesions and intermittent bleeding
Advanced disease -> lymphadenopathy, pain or difficulty with chewing or swallowing, change in speech, ear pain
Risk factors for oral cancer
- Tobacco, alcohol use
- Betel nut quid (Asia/India)
- Periodontal disease
- Radiation
- Immune deficiency
What infection is responsible for causing a tongue with prominent red papillae on a white-coated background?
“Strawberry Tongue” caused by toxin-producing Strep pyogenes
Tx for PTA
Needle aspiration or I&D
Abx choices include penicillin VK, amoxicillin and clavulanic acid, or clindamycin
Complications of PTA
- Airway obstruction
- Aspiration
- Deep space or intracranial extension
- Carotid artery injury during drainage
Which pole of the tonsil is most commonly affected in a PTA?
Superior, followed by middle, followed by inferior
What is the most common cause of viral sialoadenitis?
Mumps parotitis (usually bilateral - in contrast to bacterial parotitis which is normally unilateral)
What is the most common preceding illness that progresses into cavernous sinus thrombosis?
Acute sinusitis
Clinical presentation of cavernous sinus thrombosis
Headache is most common presenting symptom followed by fevers, periorbital edema, chemosis (conjunctival edema), cranial nerve signs
Lateral gaze palsy (isolated CN VI) most common
As infection tracks posteriorly, visual disturbances and proptosis
Periorbital edema and vision changes rapidly become bilateral due to communicating veins bridging the cavernous sinuses
Imaging modalities for cavernous sinus thrombosis
CTA screening imaging study
MRI with MR venography is preferred
Most common bacterial infection causing cavernous sinus thrombosis
Staphylococcus aureus
What serious head and neck infection is classically preceded by a dental infection?
Ludwig’s angina
What is endophthalmitis?
Infection involving anterior, posterior, and vitreous chambers of the eye
Causes of endophthalmitis
- Trauma (blunt globe rupture, penetrating injury, foreign bodies)
- Iatrogenically after ocular surgery like cataract repair
Eye exam in endophthalmitis
- Decreased visual acuity
- Injected conjunctiva
- Chemosis and haziness of infected chambers
What is a dependent pocket of pus seen in the anterior chamber called?
Hypopyon
What topical therapy can be used to help treat minor local wound infections around a tracheostomy site?
Dressing changes with gauze soaked in 0.25% acetic acid or silver-containing products
What is the term for inflammation and infection of the soft tissue overlying a partially erupted third molar, often due to embedded food particles and tooth impaction?
Pericoronitis
Physiology of acute angle-closure glaucoma
Q143445
Appearance of eye in acute angle-closure glaucoma
- Hazy cornea
- Perilimbic injection
- Poorly reactive, mid-dilated pupil (4-6mm)
Tx for acute angle-closure glaucoma
- IV acetazolamide
- topical beta-blockers (timolol)
- Topical alpha-agonists (apraclonidine)
- Topical miotic agents (pilocarpine) - may be controversial, but to be used after IOP decreased
- Topical steroids
Mannitol and glycerol can further reduce intraocular pressure
What is Adie pupil?
A pupil with parasympathetic denervation that constricts poorly to light but reacts better to accommodation, which gives the appearance of anisocoria
Four causes of afferent pupillary defect
- Glaucoma
- Retrobulbar hematoma
- Retinal pathology
- Optic neuritis
What vessel is most likely source of bleeding in posterior epistaxis?
Sphenopalatine artery - located at posterior aspect of middle nasal turbinate
Stepwise treatment of epistaxis
- Gently blow nose or suction out blood
- Direct pressure
- Apply cotton balls soaked in topical anesthetic and vasoconstrictor (1% tetracaine plus afrin)
- Chemical cautery
- Packing
What counseling should you offer parents of children with electrical burns of the lip?
Labial artery typically bleeds 2-5 days after injury. Teach parents how to hold pressure on the area
Physical exam of traumatic iritis
- Ciliary flush
- Perilimbic conjunctival injection
- Decreased acuity
- Sluggish pupil
- Consensual photophobia
- Cell and flare on slit lamp
Tx for traumatic iritis
Topical cycloplegics (cyclopentolate) Steroids may be used, but only after consultation with ophthalmology and after infection is ruled out
What is leukoplakia?
Premalignant white patch or plaque that cannot be scraped off and could progress to an ulcer or mass
What is oral hairy leukoplakia?
Associated with EBV and almost exclusive to HIV-infected patients
Cannot be scraped off
Don’t confuse with leukoplakia (precancerous lesion)
What is perichondritis?
Infection of overlying skin and perichondrium of external ear
- swollen, warm, tender and erythematous auricle and could include ear lobule
- pain on deflection of auricle (differentiates from superficial infection)
Tx for perichondritis
Fluoroquinolone
IV abx if patient is immunocompromised or h/o diabetes
Management of central retinal vein occlusion
- Ophthalmology consult
- Anti-vascular endothelial growth factor
- Dexamethasone implant
- Triamcinolone (intravitreal)
Most common type of retinal detachment
Rhegmatogenous retinal detachment - generally occurs in patients older than 45 years and associated with degenerative myopia
What is definitive surgical treatment of acute angle-closure glaucoma?
Laser iridotomy within 24-48 hours
Rinne Test
Base of tuning fork placed on mastoid bone and patient asked when sound no longer heard. Tuning fork then moved beside ear and patient asked if now audible
Normal: AC>BC (pt can hear fork at ear)
Conductive loss: BC>AC (pt will not hear fork)
Most common causes of conductive hearing loss
- Otitis media
- Serous otitis
- Cerumen impaction
Most common causes of sensorineural hearing loss
- Excessive noise exposure
- Drugs
- Normal aging
Difference between pinguecula and pterygium
Both are collagen degeneration; pinguecula occurs near limbus (cornea-sclera junction) but does not grow onto cornea
How is presbyopia different than myopia or hyperopia?
Abnormalities of corneal thickness and axial length of eyeball are more commonly thought of as causes of hyperopia (farsightedness) and myopia (nearsightedness)
In reference to ocular medications, a dark green bottle cap is indicative of what class of medicine
Miotics (pilocarpine, echothiophate)
See Q164794 for other color schemes
What is the emergent ophthalmologic condition that calls for the avoidance of all topical ocular medications?
Globe rupture
What physical exam finding is used as a screening test for retinoblastoma?
Leukocoria, or “white pupil” when checking for red reflex of the eye
Most common deep space infection of the neck?
Peritonsillar infection
What is the upper limit of normal for optic disc elevation? And for optic nerve sheath diameter?
- 6mm elevation
0. 5mm diameter
Does idiopathic intracranial hypertension present with bilateral or unilateral papilledema?
Either presentation is possible
What two spaces is the submandibular space divided into?
Sublingual and submylohyoid
